Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Santa Paula Post Acute Center during CMS and state inspections, most recent first.
A vending machine in the dining room was found with a broken plastic window screen and a note from a kitchen staff member asking others not to further damage it. The Maintenance Director was unaware of the issue and acknowledged the safety risk, while the kitchen staff member reported the machine had been broken for two weeks. The DON stated that staff should have reported the problem to maintenance, and facility policy requires maintenance to keep equipment in good repair and free from hazards.
A resident with multiple missing and broken teeth did not have a comprehensive dental care plan developed or implemented, despite documented dental concerns and facility policy requiring such plans. The DON confirmed the omission during a record review and interview.
A resident admitted with an indwelling catheter and multiple urinary diagnoses did not have timely physician orders for catheter monitoring and care. The DON confirmed that orders for catheter and drainage bag changes were delayed, and there was no documentation of monitoring or changes during the resident's stay.
The facility's fire alarm system did not transmit alarm signals to a central station when tested, as confirmed by both the Maintenance Supervisor and the central station. This deficiency affected all residents in the building, with the issue observed during a survey and attributed to a possible phone service provider problem.
Surveyors found an 'E' type oxygen cylinder freestanding and not secured in a proper stand or cart in the oxygen storage room, where the total oxygen volume exceeded 300 cubic feet. The Maintenance Supervisor confirmed the finding, which affected 38 residents in one smoke compartment.
The facility did not provide documentation that the automatic transfer switch (ATS) for the Emergency Power Supply System was exercised within the required 12-month period, with the last service occurring five days past due. This deficiency affected all residents in the facility's three smoke compartments and could result in a delay in providing emergency power during an outage.
The facility did not ensure proper sanitation practices in the kitchen and food storage areas. Staff failed to test the chemical concentration of the kitchen sanitizing solution each time it was replaced, as required by facility policy. Additionally, the ice machine was not cleaned and sanitized according to manufacturer guidelines, with only the exterior being addressed and internal cleaning steps omitted.
Two residents who had their personal funds managed by the facility reported not receiving any account statements or documentation of their account activities. Business office staff confirmed that financial statements were only provided upon request, not on a regular quarterly basis as required by facility policy.
Survey results and the plan of correction were not posted in an accessible location, with the binder stored high on a wall and missing required documents. The DON confirmed the plan of correction was not available for residents and visitors, and the facility's policy to keep these materials in a common area was not followed.
A resident's privacy curtain was found to have large tears in multiple areas, as observed during a room tour. Staff interviews confirmed the curtain's poor condition and the need for replacement, but the issue had not been addressed, potentially compromising the resident's privacy.
The facility did not complete required PASRR Level II evaluations for two residents who screened positive for serious mental illness, failing to respond to state agency communications and not initiating new screenings after significant changes in condition. The DON acknowledged the lack of follow-up and could not provide documentation supporting the omission of required assessments.
A resident with Parkinson's disease and muscle weakness, who required extensive assistance and was at risk for skin breakdown, was not turned and repositioned every two hours as outlined in their care plan. Documentation and staff acknowledgment confirmed that scheduled repositioning was missed on several occasions, contrary to facility policy.
Nursing staff did not follow or document physician's orders for flushing a resident's G-tube, as required by hospital discharge instructions. This failure led to repeated clogging of the tube and multiple hospital visits, with the DON confirming that the necessary care was not performed or recorded in the e-MAR.
A resident with a GJ feeding tube experienced repeated tube clogging, dislodgement, and damage over six months, while most medications were administered in forms likely to cause clogs. The DON was unable to explain the ongoing issues, and review of facility records confirmed that licensed nursing staff did not receive education on G-tube management, with only CNAs attending the relevant in-service training.
A CNA was hired and worked without documentation of a valid and current CNA license, despite facility policies requiring verification of certification and background checks. The Director of Staff Development confirmed responsibility for licensure tracking but could not provide evidence of an active license for the CNA.
A resident's assessments were conducted by LVNs without RN validation, contrary to professional standards requiring RN oversight. The resident experienced changes in condition, including weight loss and skin issues, which were documented by LVNs. The DON confirmed the lack of RN validation, acknowledging the oversight and its potential risk to the resident.
A resident in an LTC facility received oxygen at an incorrect flow rate, had missing documentation for G-tube site cleaning, and was administered Midodrine despite blood pressure readings exceeding the prescribed threshold. These actions were confirmed by the DON and violated physician orders.
A facility failed to follow physician orders and care plan interventions for a resident with chronic respiratory failure and hypoxia. The resident was observed receiving supplemental oxygen without an active physician order, and there was no documentation of oxygen saturation monitoring as required by the care plan.
The facility failed to lock two medication carts when left unattended, risking unauthorized access to medications. An IV cart with antibiotics and another medication cart were both found unlocked and unattended. The involved LNs acknowledged the carts should have been locked, as per the facility's policy requiring carts to be locked when out of view.
A facility failed to notify a resident's physician and responsible party of a change in condition within the required 24-hour period. The resident experienced loose stools, but the LVN delayed notification for five days. The DON confirmed this was against the facility's policy, which mandates timely communication of changes in a resident's condition.
A resident's assessments were conducted by LVNs instead of an RN, contrary to professional standards. The assessments included significant changes in the resident's condition, such as altered mental status and weight loss. The DON confirmed the assessments were done by LVNs without RN validation.
A facility failed to monitor a resident's intake and output as ordered by the physician, leading to unclear documentation and an inability to assess the resident's hydration status. The DON and MRC could not decipher the flow sheets, which placed the resident at risk of dehydration.
A resident with a history of falls and coordination issues was observed without a required wheelchair tab alarm, despite physician orders and care plan interventions mandating its use. The absence of the alarm was confirmed by the ADON and an LN, highlighting a failure to follow established care protocols.
The facility failed to submit complete and accurate staffing data to CMS for two quarters due to miscommunication with a contracted company and changes in staff job titles. The Accounts Payable/Payroll staff member was responsible for inputting payroll data, which was then submitted to the contracted company. The Assistant Administrator did not approve the data due to changes in staff roles, leading to invalid data submission.
A facility failed to resubmit a Level I PASRR for a resident who returned from the hospital with new psychiatric diagnoses and medication orders. Despite the resident's severe cognitive impairment and use of psychotropic medications, the necessary PASRR process was not followed. Facility staff were unaware of the requirement to conduct a new screening, leading to non-compliance with PASRR requirements.
Failure to Maintain Vending Machine in Good Repair Creates Safety Hazard
Penalty
Summary
The facility failed to maintain a vending machine in the resident dining room in good repair and free from hazard. During an inspection with the Maintenance Director and a kitchen staff member, it was observed that the vending machine had a broken plastic window screen and a note from the kitchen staff member requesting that issues with the machine be reported rather than further damaging the window. The Maintenance Director was not aware of the broken vending machine and acknowledged it posed a safety risk, as residents could potentially reach through the broken window and get hurt. The kitchen staff member stated that the vending machine had been in disrepair for two weeks. The Director of Nursing confirmed that staff should have notified the maintenance department about the issue. A review of the facility's maintenance policy indicated that maintenance services are to be provided to all areas of the building and equipment, and that maintenance personnel are responsible for keeping the building in good repair and free from hazards.
Failure to Develop Comprehensive Dental Care Plan
Penalty
Summary
The facility failed to develop a comprehensive dental care plan for a resident who, according to an initial dental exam, had five missing teeth and four broken teeth. During a record review and interview with the Director of Nursing (DON), it was confirmed that the dental exam findings were documented, but no care plan was created to address the resident's dental status or concerns. The DON acknowledged the absence of a care plan and confirmed that one should have been in place. Facility policy requires a comprehensive, person-centered care plan with measurable objectives and timetables for each resident, but this was not implemented for the resident in question.
Failure to Obtain Timely Physician Orders for Catheter Care
Penalty
Summary
A facility failed to obtain timely physician orders for indwelling catheter care for a resident who was admitted with a urinary tract infection, obstructive and reflex uropathy, and chronic kidney disease. The resident was admitted with an indwelling catheter, but physician orders for catheter monitoring, catheter changes, and drainage bag changes were not obtained until over a month after admission. The Director of Nursing was unable to provide an explanation for the delay in obtaining these orders. Additionally, there was no documentation available to show that the resident was being monitored for signs and symptoms of a urinary tract infection or that the indwelling catheter or drainage bag was changed from admission to discharge. Interviews with facility staff confirmed the lack of documentation and the absence of timely physician orders for appropriate catheter care during the resident's stay.
Failure to Transmit Fire Alarm Signals to Central Station
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with NFPA 70 and NFPA 72 requirements. During a tour, observation, and record review, it was found that the fire alarm system did not transmit fire signals to a central station when initiating devices were activated. Three devices were tested within a specific time frame, and none of the alarm signals were received by the central station. The Maintenance Supervisor confirmed during an interview that after testing the devices, he contacted the central station, which verified that no trouble signal had been received. This failure to transmit alarm signals was directly observed and documented during the survey process. The deficiency affected all 79 residents in the facility, spanning three smoke compartments. The Assistant Administrator confirmed the issue and attributed the problem to a possible phone service provider issue, but at the time of the survey, the fire alarm system was not functioning as required to ensure prompt transmission of fire signals to the central station.
Plan Of Correction
K 345 K345 Fire Alarm System - Testing and Maintenance K345 CORRECTIVE ACTION: ADON/Maintenance upon discovery of the alarm testing signal transmission failure to service provider: Fire watch protocols were activated per facility policy. SEE EXHIBIT - A - Fire alarm service provider (Bay Alarm) dispatch was contacted to follow up on the testing transmission disruption. - Facilities IT and telephone service provided (Frontier) were contacted to troubleshoot the communication lines. - SEE EXHIBIT - B - Bay Alarm technician inspected fire alarm panel on and reported that it was in good functioning order. - Technician referred our maintenance team to follow up with our phone service provider. K345 CORRECTIVE ACTION: ADON/Maintenance upon discovery of the alarm testing signal transmission failure to service provider: Fire watch protocols were activated per facility policy. SEE EXHIBIT - A - Fire alarm service provider (Bay Alarm) dispatch was contacted to follow up on the testing transmission disruption. - Facilities IT and telephone service provided (Frontier) were contacted to troubleshoot the communication lines. - SEE EXHIBIT - B - Telephone service provider technician inspected the telephone lines and reported that one of the land lines likely had physical damage. - Technician re-routed the landline and re-established connection to the fire alarm panel. - While technician was in the building, our maintenance team reached out to Bay Alarm to inform their central monitoring station that a test of the system would be performed. - Bay Alarm emailed the test report confirming that the test signal was received. - SEE EXHIBIT - C IDENTIFICATION OF OTHERS: Maintenance Dept/Designees were inserviced to include the monthly testing results in the monthly quality assurance meeting report. Designee will also include communication with the central station prior to system testing and include confirmation of patent signal in the monthly report. - SEE EXHIBIT - D MEASURES TO PREVENT RECURRENCE: Maintenance Dept/Designees were inserviced to inform administration during daily department manager morning meeting/report whenever testing is taking place to ensure administration is able to monitor the testing and confirm successful testing and transmission to providers' Central Station. - SEE EXHIBIT - E
Improper Storage of Oxygen Cylinder in Facility Storage Room
Penalty
Summary
During a facility tour, surveyors observed that an 'E' type oxygen cylinder was not supported in a proper cylinder stand or cart, but was instead freestanding in the oxygen storage room. The aggregate volume of oxygen stored in the room exceeded 300 cubic feet. According to NFPA 99, freestanding cylinders must be properly chained or supported to prevent abnormal mechanical shock that could damage the cylinder, valve, or safety device. The Maintenance Supervisor confirmed the observation and noted that the cylinder may have belonged to an outside agency. The deficiency affected 38 of 79 residents in one of three smoke compartments. The report specifically cites the failure to maintain oxygen cylinders in accordance with required safety standards, as the cylinder was not properly secured. No additional information about the medical history or condition of the residents involved is provided in the report.
Plan Of Correction
K923 CORRECTIVE ACTION Stand alone oxygen tanks were immediately removed from affected locations by maintenance staff and properly placed in storage dedicated oxygen storage location stands. IDENTIFICATION OF OTHERS Maintenance staff immediately completed a facility-wide sweep to ensure that no other areas and residents were affected by this deficient practice. MEASURES TO PREVENT RECURRENCE: DSD/Designee provided facility staff with an inserviced regarding our oxygen safety policies including proper handling and safe storage of portable oxygen tanks. SEE EXHIBIT - H MONITORING PROCESS: Administrator/Designee will assign the safety committee panel members designated areas of the building to inspect for inappropriately placed or stored oxygen tanks and report findings during our monthly safety committee meeting for monitoring, improvement, and implement strategies for compliance.
Failure to Timely Test and Maintain Automatic Transfer Switch for Emergency Power
Penalty
Summary
The facility failed to maintain the Emergency Power Supply System (EPSS) in accordance with regulatory requirements. Specifically, the facility did not provide documentation that the automatic transfer switch (ATS) was exercised within the last 12 months, as required by NFPA 110. The last preventative maintenance and ATS service was completed on 4/17/24, which was five days past due at the time of the survey. This lapse was confirmed during a record review and interview with the Maintenance Supervisor, who acknowledged that the vendor was scheduled to perform the service the following week. This deficiency affected all 79 residents in three smoke compartments, as the ATS is critical for ensuring timely transfer of power during emergencies. The lack of timely testing and maintenance of the ATS could result in a delay in providing emergency power to selected areas of the facility, as directly stated in the report. No additional details about the residents' medical history or condition at the time of the deficiency were provided.
Plan Of Correction
K918 CORRECTIVE ACTION Maintenance Supervisor/Designee immediately contacted our backup generator service provider to follow up on service delay as we are contracted to have the generator serviced yearly. Additionally, an inservice was provided to our maintenance staff regarding the generator service and maintenance. SEE EXHIBIT - F IDENTIFICATION OF OTHERS Maintenance Supervisor/Designee immediately reviewed equipment and facility maintenance logs to ensure no other equipment was affected by this deficient practice. MEASURES TO PREVENT RECURRENCE Maintenance log reports and findings will be reviewed by the quality assurance panel during monthly and quarterly reports. Findings and suggestions for improvement will be included in the QA report. MONITORING PROCESS Maintenance Supervisor/Designee were inserviced to include the completed maintenance report findings of all regularly serviced equipment and facility inspections in our quarterly assurance meetings, including dates of upcoming scheduled maintenance. SEE EXHIBIT - G IDENTIFICATION OF OTHERS Maintenance Supervisor/Designee immediately reviewed equipment and facility maintenance logs to ensure no other equipment was affected by this deficient practice. MEASURES TO PREVENT RECURRENCE Maintenance log reports and findings will be reviewed by the quality assurance panel during monthly and quarterly reports. Findings and suggestions for improvement will be included in the QA report. MONITORING PROCESS Maintenance Supervisor/Designee were inserviced to include the completed maintenance report findings of all regularly serviced equipment and facility inspections in our quarterly assurance meetings, including dates of upcoming scheduled maintenance. SEE EXHIBIT - G
Failure to Maintain Kitchen and Ice Machine Sanitation Standards
Penalty
Summary
The facility failed to maintain proper kitchen and food storage sanitation in two key areas. First, the sanitizing solution used in the kitchen was not routinely tested for chemical concentration each time it was replaced, despite being changed every two hours. During observation, the Interim Dietary Supervisor confirmed that staff did not test the solution with each replacement, which was contrary to the facility's own policy requiring testing prior to usage. The chemical concentration was only checked during the survey, and the policy and logs indicated that testing should occur with every new batch of solution. Second, the facility did not follow manufacturer guidelines for cleaning and sanitizing the ice machine. The Maintenance Supervisor reported that cleaning and sanitizing procedures were performed only on the exterior of the ice machine, using appropriate cleaning and sanitizing agents. However, the manufacturer's instructions required a more thorough process, including internal cleaning and sanitizing steps such as circulating cleaning and sanitizing solutions through the machine's water trough and internal components. Review of the facility's cleaning logs confirmed that these internal procedures were not performed as required.
Failure to Provide Quarterly Resident Financial Statements
Penalty
Summary
The facility failed to provide individual financial account statements to residents on a quarterly basis as required. During interviews, two residents confirmed that the facility held their personal funds for safekeeping but had not provided them with any documentation or statements regarding their account activities. The business office staff acknowledged that account statements were only given upon request and not routinely, and the facility's policy indicated that quarterly statements should be made available to residents. This lapse resulted in residents not being routinely informed of their personal funds account activity.
Survey Results and Plan of Correction Not Readily Accessible
Penalty
Summary
The facility failed to ensure that the most current survey results and the associated plan of correction were posted in a location that was easily accessible to residents and the public. During an observation with the Administrator Assistant, the survey results binder was found stored high on a wall outside the medical records office, making it difficult for residents in wheelchairs to access without assistance. Additionally, during a review with the Director of Nursing, it was discovered that the plan of correction was missing from the binder available for residents and visitors. The facility's policy requires that these documents be maintained in a 3-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room, but this was not being followed.
Privacy Curtain in Disrepair Compromises Resident Privacy
Penalty
Summary
The facility failed to ensure that privacy curtains were in good condition for one of four sampled residents. During an initial tour of the resident's room, surveyors observed that the privacy curtain on the right side of the resident's bed had large tears in multiple areas. Interviews with a licensed nurse, the maintenance supervisor, and the housekeeping supervisor confirmed the presence of the tears and acknowledged that the curtain needed to be replaced. The facility's policy indicated that maintenance service should be provided to all areas of the building, grounds, and equipment, but the torn curtain had not been addressed at the time of the survey. This deficiency was identified through direct observation and staff interviews, with the potential for the resident's privacy to be compromised due to the condition of the curtain.
Failure to Complete Required PASRR Follow-Up for Residents with Mental Disorders
Penalty
Summary
The facility failed to follow up on positive Level I Preadmission Screening and Resident Reviews (PASRR) for two residents who screened positive for serious mental illness (SMI). For one resident, the admission record showed diagnoses including unspecified psychosis, unspecified mood affective disorder, and schizophrenia. Documentation from the Department of Health Care Services (DHCS) indicated a positive PASRR Level I screening, but the Level II evaluation was not completed because facility staff were unresponsive to multiple attempts at communication from DHCS. No new Level I PASRR was completed after the case was closed, and the Director of Nursing (DON) could not provide documentation to support the decision not to pursue a Level II PASRR. For another resident, the medical record indicated diagnoses of Alzheimer's, dementia, and unspecified psychosis, with a positive PASRR Level I screening for SMI. The facility did not follow up with a Level II PASRR, and DHCS records showed staff were unresponsive to communication attempts. Additionally, after a significant change in condition to hospice care, a new PASRR screening was not initiated. The DON acknowledged that follow-up was not made and that a PASRR Level I screening should have been completed after the change in condition. Facility policy requires referral for Level II evaluation when Level I screening is positive for mental disorder, intellectual disorder, or related disorder.
Failure to Implement Scheduled Repositioning for Resident at Risk of Skin Breakdown
Penalty
Summary
A review of the health record for a resident with Parkinson's disease and muscle weakness revealed that the resident required extensive assistance with physical functioning, including bed mobility, transfers, eating, and toileting. The Minimum Data Set assessment indicated the resident needed substantial or maximal assistance for various movements such as rolling, sitting, and transferring. The care plan identified the resident as being at risk for skin breakdown and included an intervention to turn and reposition the resident every two hours. However, documentation showed that on multiple dates, the resident was not turned and repositioned as required by the care plan. This was confirmed during an interview and record review with the director for staff development, who acknowledged the resident was not turned every two hours. The facility's policy on repositioning states that bedbound residents should be repositioned at least every two hours to prevent skin breakdown and provide pressure relief.
Failure to Implement and Document G-Tube Care Orders
Penalty
Summary
Nursing staff failed to implement physician's orders and hospital discharge recommendations regarding the care and flushing of a resident's gastrostomy/jejunostomy (G-tube) feeding tube. The resident, who had diagnoses including left hemiparesis, dysphasia, a gastrostomy tube, and glioblastoma multiforme, required specific management of the G-tube, including flushing the jejunostomy port with 60 ml water at least every four hours and flushing the gastrostomy port with 60 ml water after administering medications. Despite these clear instructions, record reviews showed that the required care was not documented or carried out, as evidenced by blank entries in the electronic medication administration records (e-MAR) over several months. The deficiency was further substantiated by multiple documented incidents of the resident's G-tube becoming clogged, which led to repeated hospital visits. During interviews, the DON confirmed that the instructions were not implemented by licensed nurses, as indicated by the lack of documentation in the e-MAR. The failure to follow physician's orders and properly document care resulted in the resident experiencing frequent G-tube clogging.
Failure to Manage G-Tube and Educate Licensed Staff
Penalty
Summary
The facility failed to properly manage a resident's gastrostomy/jejunostomy (GJ) feeding tube and did not provide adequate education to licensed nursing staff regarding G-tube management. Over a six-month period, the resident, who had a history of left hemiparesis, dysphasia, a G-tube, and glioblastoma multiforme, experienced repeated issues with the GJ tube, including frequent clogging, dislodgement, tearing, and rupture. Documentation showed multiple incidents where the tube was clogged, pulled out, or damaged, and the resident was often administered medications in capsule and tablet form, which may have contributed to the tube's frequent clogging. The DON acknowledged that such persistent problems with a G-tube were not typical and could not explain why the issues persisted or why medications were not adjusted to prevent clogging. Additionally, the facility did not provide education on G-tube management to licensed nursing staff during the relevant period. Review of the facility's education binder and interviews with the director of staff development (DSD) confirmed that no training on enteral feeding or G-tube management was conducted for licensed nurses in 2024. An in-service session on enteral feeding was held, but attendance records showed that only one registered nurse and one assistant director of nursing participated, with the majority of attendees being certified nursing assistants. This lack of education for licensed staff contributed to the ongoing issues with the resident's G-tube.
Failure to Verify CNA Licensure Prior to Employment
Penalty
Summary
A review of the facility's employee records revealed that an individual was hired as a certified nursing assistant (CNA) without documentation of a valid CNA license number on the Employee Spreadsheet Roster. The facility's job description for CNAs requires current state certification, and the policy and procedure for background screening specifies that the state nurse aide registry should be checked for findings related to abuse, neglect, or mistreatment, and that licensing boards should be contacted for any sanctions. During an interview, the Director of Staff Development confirmed responsibility for monitoring CNA licensure and stated that applicants would not be hired without an active license. However, the lack of documentation for the CNA's license indicated a failure to ensure that the employee held a valid and up-to-date certification while working in the facility.
Failure to Ensure RN Conducted Resident Assessments
Penalty
Summary
The facility failed to ensure that assessments for a resident were performed by a registered nurse (RN) as required by professional standards of practice. According to the Nursing Practice Act, an RN is responsible for conducting comprehensive assessments, which include data collection, analysis, and making clinical judgments. However, the assessments for the resident, who experienced a change of condition including weight loss, skin discoloration, abdominal distention, and a dry scab, were conducted by licensed vocational nurses (LVNs) without RN validation or cosignature. This practice is outside the LVN's scope, as they are not prepared to make RN-level nursing judgments or assessments independently. During a review of the resident's documents, it was confirmed by the Director of Nursing (DON) that the assessments were conducted by LVNs. The DON acknowledged that the assessments were not validated by an RN, which is a requirement to ensure a comprehensive and accurate plan of care. This oversight had the potential to place the resident at risk of not being assessed appropriately, which could result in harm. The DON indicated an understanding of the issue and mentioned the possibility of adding an RN's signature to the assessment documents for validation.
Failure to Follow Physician Orders for Oxygen, G-tube Care, and Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for a resident, resulting in multiple deficiencies. Firstly, the resident was observed receiving oxygen at a flow rate of 3 liters per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was confirmed by the Director of Nursing (DON) and the Administrator during an observation. Additionally, the Treatment Administration Record (TAR) for the resident showed missing staff initials for G-tube site cleaning, which was ordered to be performed twice daily. The missing entries were noted on specific dates, and the DON acknowledged that the absence of documentation implies the task was not completed. Furthermore, the facility did not follow physician orders regarding the administration of Midodrine, a medication intended to increase blood pressure. The orders specified that the medication should be withheld if the resident's systolic blood pressure (SBP) exceeded 110 mmHg. However, the Medication Administration Record (MAR) indicated that the medication was administered 18 times despite the SBP being above the specified threshold. The DON confirmed this oversight, acknowledging that the medication was given when it should have been held, as per the facility's policy and procedure for administering medications.
Failure to Follow Physician Orders for Supplemental Oxygen
Penalty
Summary
The facility failed to follow physician orders and a care planned intervention for supplemental oxygen for a resident diagnosed with chronic respiratory failure with hypoxia. During an observation, the resident was seen wearing a nasal cannula and receiving supplemental oxygen between two to three liters per minute. However, upon review, it was found that there was no active physician order for the supplemental oxygen being administered to the resident. Additionally, the facility did not provide documentation indicating that staff were monitoring the resident's oxygen saturation levels each shift, as required by the care plan, from mid-July to mid-August. The facility's policies and procedures for administering medications and oxygen require verification of a physician's order and adherence to the care plan, which were not followed in this case.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that two medication carts were locked when left unattended, which could lead to unauthorized access to medications. During an observation and interview, an IV cart containing antibiotics was found unlocked and unattended. The licensed nurse acknowledged that the cart should have been locked. In a separate incident, another medication cart was observed unlocked and unattended for five minutes. The licensed nurse involved also confirmed that the cart should have been locked. The facility's policy and procedure on the security of medication carts, dated April 2007, states that medication carts must be securely locked at all times when out of the nurse's view.
Failure to Notify Physician and Responsible Party of Change in Condition
Penalty
Summary
The facility failed to ensure timely notification of a resident's change of condition to the physician and responsible party, as per their policy. A review of the medical record for a resident revealed that a change of condition, specifically loose stools, was identified on 5/29/24. However, the nursing staff, specifically an LVN, did not notify the physician and responsible party until 6/3/24, which was five days after the change was noted. During an interview, the Director of Nursing (DON) confirmed that the LVN did not adhere to the facility's policy, which mandates notification within 24 hours of a change in a resident's condition. The facility's policy, dated 2/2021, requires prompt notification of changes in a resident's medical or mental condition to the resident, their attending physician, and their representative within 24 hours, except in medical emergencies.
Failure to Ensure RN Conducted Resident Assessments
Penalty
Summary
The facility failed to ensure that a resident's assessments were performed by a registered nurse (RN) as required by professional standards of practice. According to the Nursing Practice Act, an RN is responsible for conducting comprehensive assessments, which include data collection, analysis, and making clinical judgments. However, the initial assessment upon the resident's readmission from the hospital was conducted by two licensed vocational nurses (LVNs), which is outside their scope of practice. The Director of Nursing (DON) confirmed that the initial assessment was performed by LVNs, with one assessing the skin and the other conducting the rest of the assessment. Further review of the resident's records revealed multiple instances where assessments were conducted by LVNs without RN validation or cosignature. These assessments included significant changes in the resident's condition, such as altered mental status, significant weight loss, loose stools, difficulties breathing, elevated blood pressure, and a skin tear. The DON acknowledged that these assessments were conducted by LVNs and recognized that it is not within their scope of practice to perform assessments independently.
Failure to Monitor Resident's Hydration Status
Penalty
Summary
The facility failed to ensure proper monitoring of a resident's intake and output, as well as evaluating the resident's hydration status as ordered by the physician. The resident, a male who was readmitted to the facility after a cholecystectomy, had physician orders to monitor intake and output for hydration every shift. However, the documentation on the intake and output measurement flow sheets for March, April, May, and June was incomplete, confusing, and contained numerous blanks, making it impossible to determine the resident's fluid intake and output accurately. The Director of Nursing (DON) and the Medical Records Clerk (MRC) were unable to decipher the documentation on the flow sheets during a review and interview. They could not determine the fluid amounts consumed or excreted by the resident in a 24-hour period, nor could they calculate the net fluid balance to assess the resident's hydration status. This lack of clarity and oversight in documentation placed the resident at risk of dehydration without staff being aware of it.
Failure to Implement Wheelchair Tab Alarm for Resident
Penalty
Summary
The facility failed to adhere to a physician's order and a care plan intervention for a resident who required a wheelchair tab alarm. This deficiency was identified during an observation and interview with the Assistant Director of Nursing (ADON 1) and a Licensed Nurse (LN 1). The resident, who was admitted with diagnoses including lack of coordination, difficulty in walking, and repeated falls, was observed seated in a wheelchair without the required tab alarm. Both ADON 1 and LN 1 confirmed that the tab alarm should have been in place as per the physician's order dated 5/3/24 and the care plan intervention initiated on 2/26/24. The resident's medical records and care plan indicated that a tab alarm was necessary to alert staff when the resident attempted to get out of bed or the wheelchair unassisted, due to the risk of falls and injury. The facility's policy on comprehensive, person-centered care plans emphasized the importance of implementing such interventions to maintain the resident's highest practicable well-being. The absence of the tab alarm, as observed, was a direct violation of these orders and policies, potentially compromising the resident's safety.
Failure to Submit Accurate Staffing Data to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the fourth quarter of fiscal year 2023 and the first quarter of fiscal year 2024. The facility's policy required that staffing data be reported electronically through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS, no less frequently than quarterly. However, a review of the PBJ Staffing Data Report revealed that the facility did not submit data for the fourth quarter of FY 2023, and the metric for Excessively Low Weekend Staffing was suppressed for the first quarter of FY 2024 due to invalid data. Interviews with facility staff revealed that the Accounts Payable/Payroll staff member was responsible for inputting payroll data, which was then submitted to a contracted company for transmission to CMS. The Director of Nursing and the Assistant Administrator confirmed that a miscommunication with the contracted company led to the failure to submit data. The Assistant Administrator acknowledged that changes in staff job titles, such as CNAs becoming LVNs and an LVN becoming an RN, contributed to the submission of invalid data. The facility depended on the contracted company to verify the submission of the PBJ data, but the Assistant Administrator did not approve the data due to these changes, resulting in the failure to submit the required information to CMS.
Failure to Resubmit PASRR for Resident with New Psychiatric Diagnoses
Penalty
Summary
The facility failed to resubmit a Level I Preadmission Screening and Resident Review (PASRR) for a resident who received new mental illness diagnoses. The resident was originally admitted with a negative Level I PASRR screening, indicating no need for a Level II screening. However, after being readmitted from the hospital with new diagnoses of dementia with mood disturbance, psychotic disturbance, and major depressive disorder, the facility did not conduct a new Level I PASRR screening. The resident's care plan and medical records indicated severe cognitive impairment and the use of psychotropic medications, but the necessary PASRR process was not followed. Interviews with facility staff revealed a lack of awareness regarding the need to resubmit a Level I PASRR screening upon the resident's return from the hospital with new psychiatric diagnoses and medication orders. The Director of Nursing and the Assistant Administrator acknowledged that the facility's policy required a new PASRR screening under these circumstances, but it was not completed. This oversight resulted in non-compliance with the PASRR requirements for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 109 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Santa Paula
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. John's Hospital Camarillo D/p Snf | 8.2 mi | ★★★★★ | 0 | 0 |
| Camarillo Healthcare Center | 9.4 mi | ★★★★★ | 0 | 0 |
| Greenfield Care Center Of Fillmore, Llc | 9.6 mi | ★★★★★ | 11 | 0 |
| Alta Healthcare Center Of Camarillo | 9.9 mi | ★★★★★ | 0 | 0 |
| Coastal View Healthcare Center | 9.9 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.